The 49^th annual meeting of Japan Biliary Association was held on September 19-20, 2013 at Chiba wih the main thema " Challenge for Innovation in Professionalism". In the presidential address I told five different sections as follows. 1. The history of biliary tract diseases and biliary surgery. 2. The history of percutaneous biliary cholangiography and the contribution of our department to its development 3. Recent clinical and experimental research of our department in biliary surgery 4. Professinonalism for physician and Challenge for innovation 5. The memory of Japan Biliary Association and acknowledgement I would like to talk about the attitude of " challenge for innovation" as academic physician from my personal experiences. The importance of these attitudes was addressed for especially young doctors in the audience. I have always kept this attitude in the clinical practice and research work from post-graduate time to the present time. I hoped to demonstrate the medical implications of this attitude, " Challenge for Innovation" for all physician's who have faced to the patients.

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Selective cannulation to the bile duct, that is, biliary cannulation is the basic for diagnosis and treatment technique of a biliary disease which needs ERCP. There are patients with difficulty in cannulation to the bile duct at a certain ratio, even if any excellent surgeon performs. Therefore, various attempts have been conducted to improve the success rate. This paper explains how procedural accidents are prevented and how the success rate of biliary cannulation is improved based on our cases as well as the literature discussion.

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Since portal vein embolization has been incorporated in the standard preoperative patient's care, hemihepatectomy or more extended hepatectomy is considered as a first-line surgical approach for perihilar cholangiocarcinoma. In present, various type of hepatectomy performed has been organized in four procedures: left hepatectomy, left trisectionectomy, right hepatectomy, and right trisectionectomy, with routine caudate lobectomy. Each hepatectomy has a specific line of resection of the intrahepatic bile duct, exclusively depending on the topological relationship between the biliary duct and portal vein. Therefore, the current radiologic diagnosis has focused on the main tumor location (Bismuth type), and presence or absence of the involvement at the estimated ductal stump in each hepatectomy; thereby, the suitable procedure among the four is scheduled. Herein, the intraoperative resection line of the duct is displayed graphically, and selection of the surgical procedure is outlined, according to Bismuth classification. Because candidates for definitive surgery require biliary drainage only in the future liver remnant, even non-surgeons should comprehend the characteristics of each hepatectomy.

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Since the survival benefit of combined gemcitabine plus cisplatin therapy (GC therapy) over gemcitabine alone has been demonstrated in randomized controlled clinical trials, the GC therapy has been recognized as a standard therapy for unresectable biliary tract cancer. On the other hand, in a randomized phase II study comparing combined gemcitabine plus S-1 chemotherapy (GS therapy) and S-1 alone, GS therapy also showed promising activity against biliary tract cancer. Based on these results, a phase III study comparing GS therapy with GC therapy is currently under investigation. No standard treatment has established in the second-line therapy or adjuvant therapy after surgery for biliary tract cancer. Phase III studies using gemcitabine or S-1 are conducted as adjuvant therapy in Japan. New molecular targeted agents are currently under investigation in a second line. Standard treatments of the second line therapy and adjuvant therapy would be established in the near future.

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We developed a radiation protection device in an attempt to reduce the level of scattered-X-ray in the examination room during ERCP examination. The device has a simple design in which four pieces of lead-woven protection fabric is fixed onto the collimator cover of the fluoroscopic unit with belt and hook-and-loop fastener, and suspended down from the cover. The device is also applicable to other commonly used fluoroscopy unit such as over-tube model, with minor adjustments to the device. The protection device was effective in reducing the level of scattered-X-ray in the examination room specifically near the fixed position of the staff, by 1/50 to 2/3. The level of examinee's effective dose was significantly reduced from its highest value of 3.1 mSv/month to less than 0.1. The level of equivalent dose at lens was also significantly reduced from its highest value of 6.9 mSv/month to 0.5. The level of examinee's exposure to the scattered-X-ray reflected from the device increased by 20%as compare to its level without the device, however, the increase was only less than 0.6%when it is compared to the level of entrance surface dose. The device is assumed to be safe based on these findings.

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In surgery for carcinoma of the lower biliary tract, pancreaticoduodenectomy, bypass, and transduodenal papillectomy are performed via a laparoscopic approach. The current status of these surgeries is summarized referring to literature in Japan and other countries. Laparoscopic pancreaticoduodenectomy is increasingly being performed, and relatively favorable outcomes in many cases have been reported in other countries. This surgery may become widespread in the future as a procedure beneficial for patients because of its low invasiveness, but investigation of its feasibility with regard to curability, such as level-2 lymph node dissection and the range of bile duct resection often discussed in Japan, has been insufficient. On the other hand, laparoscopic surgery is more difficult than open surgery, and the operative time is likely to be longer. Since the feasibility of the technique can be increased by simplification, to generalize laparoscopic pancreaticoduodenectomy safely, it is necessary to identify the feasible range compatible for both techniques and surgical oncology.

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A 71-year-old man was diagnosed as having a polyp in the gallbladder by US 2 years ago. He was referred to our hospital for work-up because of the growth of the polyp. Various imaging modalities revealed that the lesion in the size of 20 mm had almost smooth margin and fat component in the center, while the lesion partially had irregular mucosa, thick stalk and notch in the fundus of the gallbladder. Considering gallbladder cancer based on the latter, we performed the total resection of the gallbladder with the gallbladder fossa. Pathological findings of the resected specimen showed the lesion was gallbladder carcinoma with fat tissue and calcified component which is very rare and difficult to diagnose before surgery. The remarkable fibrous change and proliferation of irregular vessels were found around carcinomatous glands in the center. The subserosal tissue with fat in the fundus of the gallbladder was dragged toward the carcinoma accompanied with inflammation, which would cause the fat tissue in the carcinoma.

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The patient was a 79-year-old man with dilation of the left bile duct that was observed during follow-up abdominal CT after surgery for cecal cancer. Abdominal MRI, 11 months later, showed a tumorous lesion (26×18 mm) that was slightly enhanced at the umbilical portion of the intrahepatic bile duct. A localized grayish white papillary tumor was observed by peroral cholangioscopy. Under the diagnosis of intraductal papillary neoplasm, extended left hepatic and caudate lobectomy was performed. In the resected specimen, the left bile duct was filled with serous liquid, and a localized papillary tumor (23×13×12 mm) was observed in the intrahepatic bile duct of the left lobe. Pathologically, the tumor consisted of columnar cells containing abundant mucin in the cytoplasm, which proliferated in a papillary pattern in the bile duct; however, the grade of nuclear atypia was slight. The tumor was diagnosed as gastric-type IPNB, which was judged to be a borderline lesion. This case followed a gentle and quiet course, and is considered a valuable case to report the clinical condition of this tumor.

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After the development of double-balloon endoscope, ERCP for the patients with histories of Roux-en-Y reconstruction has become widely spreading. We reported three successful cases of biliary tract disease with Roux-en-Y reconstruction treated by ERCP using PCF-PQ260L. Case 1 was a 69-year-old female with a history of stomach-preserving Roux-en-Y reconstruction was admitted for cholangitis due to malignant biliary obstruction. She had been performed ERCP using PCF-PQ260L with overtube for double-balloon endoscope. After reaching at the hepaticojejunostomic site, we succeeded in self-expandable metallic stenting in left hepatic duct. Case 2 and 3 were males with a history of total gastrectomy with Roux-en-Y reconstruction were admitted for cholangitis. ERCP using PCF-PQ260L had been performed in both cases. After reaching at the duodenal papilla, we performed endoscopic papillary large balloon dilation in addition to EST in case 3. Thus, we succeeded in removing bile duct stone in both cases. For the patients with biliary tract disease with Roux-en-Y reconstruction, ERCP PCF-PQ260L may be a new option of endoscope.

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An 82-year-old man was admitted to our hospital for obstructive jaundice due to gallbladder and common bile duct stones. The common bile duct stones were successfully removed by endoscopic sphincterotomy (EST). Thereafter, he frequently suffered from gallstone attacks, and elective laparoscopic cholecystectomy was scheduled. However, he suddenly suffered from hematemesis, and underwent emergency endoscopy, which revealed a small amount of bleeding via the papilla of Vater. Subsequent CT and MRI revealed intraperitoneal bleeding. He underwent laparotomy, when a perforated gallbladder filled with blood and gallstones were found, which seemed to account for intraperitoneal bleeding. Intraoperative cholangioscopy showed no bleeding lesions in the bile duct. He underwent cholecystectomy and choledochoduodenostomy. Hemorrhagic cholecystitis with gastrointestinal and intraperitoneal bleeding is very rare. However, the possibility of hemorrhagic cholecystitis should be considered in patient with gallstone and concomitant intraperitoneal bleeding.

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A 79-year-old man was referred to his doctor because of epigastralgia and upper gastrointestinal fiberscopy showed a tumor of papilla of Vater (PV). After admission to our hospital, Abdominal CT showed not only a tumor of PV but elevated leision of the common bile duct (CBD) and mass in the main pancreatic duct (MPD). Under a diagnosis of triple cancer of PV, CBD and pancreas, pancreatoduodenectomy was performed. Histopathologically, all of the three lesions were papillary adenocarcinoma. The tumor of CBD had extensive intraepithelial spread toward the PV but separate from the tumor of PV. On the other hand, the tumors of PV and pancreas were directly communicated with intraepithelial carcinoma. On immunohistochemical staining, MIB-1 labeling indexes differed between the tumors of the CBD and PV or pancreas. We thus diagnosed double cancer of the CBD and PV. To our knowledge, only 9 cases (including our case) of synchronous double cancer involving the CBD and PV have been reported in the literature.

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An 81-year-old woman was diagnosed with a gall bladder tumor that was increasing in size during the follow-up for chronic non-specific enterocolitis. Surgery for suspected gallbladder cancer was scheduled. Although invasion into the liver was not obvious, we suspected that tumor invasion extended beyond the muscularis propria. Because the patient's general condition was not satisfactory, given her advanced age, we decided to opt for minimally invasive surgery. Therefore, laparoscopic cholecystectomy and radiofrequency ablation of the liver bed was performed. On pathology, adenoendocrine cell carcinoma of the gallbladder was diagnosed. The postoperative course was uneventful. Currently, at 4 years 3 month after surgery, the patient is alive without recurrence. Adenoendocrine cell carcinoma of the gallbladder is rare and is associated with poor prognosis. Few cases of long-term survival have been reported. A literature review did not identify any report on radiofrequency ablation of the liver bed for gallbladder cancer. Here, we describe the clinical features of this disease and show that radiofrequency ablation is a possible treatment option for gallbladder cancer.

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A 68-year old man, who was diagnosed with hilar cholangiocarcinoma, had an en bloc resection of his left lobe of the liver and extrahepatic bile duct. Biliary reconstruction was performed by hepatico-jejunostomy in Roux-en Y style, with total three anastomoses to B5, B8, and posterior branch. Nineteen days after the operation, an abscess formation was found around hepatico-jejunostomy due to a leakage from the anastomosis of B5 branch. In order to recover from this issue, we applied the magnetic compression anastomosis. Firstly the PTBD of B5 branch was done to create an insertion route for a guidewire of the magnet, attached to the tip of a guidewire. Under radiographic guidance, the inserted magnet through the catheter in B5 branch was attracted to another magnet that was inserted into jejunal limb, through the walls of the intestine. Six days after the maneuver, these magnets formed a new anastomosis between B5 branch and the jejunum without any complication, resulting in a successful harvest of the magnets. Although it was needed to leave a 10 Fr-sized catheter in the new anastomosis of B5 for three months, we have not experienced anastomotic stenosis or cholangitis in this case for six months after the treatment.

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Between April 1977 and December 2010, a total of 574 patients underwent resection. The incidence of major hepatectomies has increased, and limited resections, including central hepatectomies and bile duct resections, were rarely performed. Combined vascular resection was being utilized more often. Operative time has become shorter, and intraoperative blood loss has also decreased significantly. Due to refinements in surgical techniques and perioperative management, morbidity has decreased significantly, but was still high. Mortality has also decreased significantly (P<0.001), from 11.1% (=8/72) before 1990 to 1.4% (=3/218) in the last 5 years. The survival for the 574 study patients (including all deaths) was 32.5% at year 5. The survival was significantly better in the later period of 2001-2010 than in the earlier period of 1977-2000 (38.1% vs. 23.1% at year 5, P<0.001). For pM0, R0, and pN0 patients (n=243), the survival in the later period was good with 67.1% at year 5. For pM0, R0, and pN1 patients (n=142), however, the survival in the later period was similar to that in the earlier period (22.1% vs. 14.6% at year 5, P=0.647). Surgical treatment for perihilar cholangiocarcinoma has been evolving steadily, with expanded surgical indication, decreased mortality, and increased survival. Survival for R0 and pN0 patients was satisfactory, while that for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.

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